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A Pilot Study of Family-Based Exposure-Focused Treatment for Youth with Autism Spectrum Disorder and Anxiety

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Abstract

Anxiety is a common and impairing condition in youth with autism spectrum disorders (ASD). Evidence supports the use of cognitive behavioral therapy for treating anxiety in this population; however, available treatment protocols may be difficult to implement outside of research settings. The present study examined the efficacy of family-based exposure-focused treatment (FET) compared to a treatment as usual (TAU) control in 32 youth aged 6–17 years with ASD and co-occurring anxiety. Fourteen youth were randomized to FET, which included 12 face-to-face weekly therapy sessions lasing 45–55 min, while 18 youth completed the TAU control where engagement in psychotherapy or pharmacotherapy was at the discretion of the families. Results strongly supported FET with a 79% (versus 0% in TAU) response rate, 86% (versus 0% in TAU) remission in primary anxiety diagnosis, and large between-group effects on clinician-rated anxiety severity and most parent-rated domains of anxiety-related impairment. Among treatment responders, 2-month follow-up supported maintenance of gains. Overall, the study supported FET as a relatively brief intervention for the treatment of anxiety in youth with ASD, although further research is needed to replicate these findings and compare FET outcomes to more comprehensive interventions.

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Notes

  1. Data were collected before use of the ADOS-2 and WASI-II.

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References

  1. American Psychiatric Association (2013) Diagnostic and statistical manual of mental disorders, 5th edn. American Psychiatric Publishing, Arlington

    Google Scholar 

  2. Sturm A, Rozenman M, Chang S, McGough JJ, McCracken JT, Piacentini JC (2018) Are the components of social reciprocity transdiagnostic across pediatric neurodevelopmental disorders? Evidence for common and disorder-specific social impairments. Psychiatr Res 264:119–123

    Google Scholar 

  3. Davis TE III, White SW, Ollendick TH (2014) Handbook of autism and anxiety. Springer, New York

    Google Scholar 

  4. Bradley EA, Summers JA, Wood HL, Bryson SE (2004) Comparing rates of psychiatric and behavior disorders in adolescents and young adults with severe intellectual disability with and without autism. J Autism Dev Disord 34(2):151–161

    PubMed  Google Scholar 

  5. Mattila M-L, Hurtig T, Haapsamo H, Jussila K, Kuusikko-Gauffin S, Kielinen M et al (2010) Comorbid psychiatric disorders associated with asperger syndrome/high-functioning autism: a community- and clinic-based study. J Autism Dev Disord 40(9):1080–1093

    PubMed  Google Scholar 

  6. Simonoff E, Pickles A, Charman T, Chandler S, Loucas T, Baird G (2008) Psychiatric disorders in children with autism spectrum disorders: prevalence, comorbidity, and associated factors in a population-derived sample. J Am Acad Child Adolesc Psychiatr 47(8):921–929

    Google Scholar 

  7. White SW, Oswald D, Ollendick T, Scahill L (2009) Anxiety in children and adolescents with Autism Spectrum Disorders. Clin Psychol Rev 29(3):216–229

    PubMed  PubMed Central  Google Scholar 

  8. van Steensel FJA, Bögels SM, Perrin S (2011) Anxiety disorders in children and adolescents with autistic spectrum disorders: a meta-analysis. Clin Child Fam Psychol Rev 14(3):302–317

    PubMed  PubMed Central  Google Scholar 

  9. Wood JJ, Gadow KD (2010) Exploring the nature and function of anxiety in youth with autism spectrum disorders. Clin Psychol Sci Pract 17(4):281–292

    Google Scholar 

  10. Zaboski BA, Storch EA (2018) Comorbid autism spectrum disorder and anxiety disorders: a brief review. Futur Neurol 13(1):31–37

    Google Scholar 

  11. Kerns CM, Kendall PC, Berry L, Souders MC, Franklin ME, Schultz RT et al (2014) Traditional and atypical presentations of anxiety in youth with autism spectrum disorder. J Autism Dev Disord 44(11):2851–2861

    PubMed  PubMed Central  Google Scholar 

  12. Ghaziuddin M (2002) Asperger syndrome: associated psychiatric and medical conditions. Focus Autism Other Dev Disabil 17(3):138–144

    Google Scholar 

  13. Gillott A, Furniss F, Walter A (2001) Anxiety in high-functioning children with autism. Autism 5(3):277–286

    PubMed  Google Scholar 

  14. Matson JL, Love SR (1990) A comparison of parent-reported fear for autistic and nonhandicapped age-matched children and youth. Australia N Z J Dev Disabil 16(4):349–357

    Google Scholar 

  15. Ung D, Wood JJ, Ehrenreich-May J, Arnold EB, Fujii C, Renno P et al (2013) Clinical characteristics of high-functioning youth with autism spectrum disorder and anxiety. Neuropsychiatry 3(2):147–157

    Google Scholar 

  16. Vasa RA, Mazurek MO (2015) An update on anxiety in youth with autism spectrum disorders. Curr Opin Psychiatr 28(2):83–90

    Google Scholar 

  17. Kaat AJ, Gadow KD, Lecavalier L (2013) Psychiatric symptom impairment in children with autism spectrum disorders. J Abnorm Child Psychol 41(6):959–969

    PubMed  Google Scholar 

  18. Mills R, Wing L (2005) Researching interventions in ASD and priorities for research: surveying the membership of the NAS. National Autistic Society, London

    Google Scholar 

  19. Sukhodolsky DG, Scahill L, Gadow KD, Arnold LE, Aman MG, McDougle CJ et al (2008) Parent-rated anxiety symptoms in children with pervasive developmental disorders: frequency and association with core autism symptoms and cognitive functioning. J Abnorm Child Psychol 36(1):117–128

    PubMed  Google Scholar 

  20. Davis TE, Moree BN, Dempsey T, Reuther ET, Fodstad JC, Hess JA et al (2011) The relationship between autism spectrum disorders and anxiety: the moderating effect of communication. Res Autism Spectr Disord 5(1):324–329

    Google Scholar 

  21. Green SA, Ben-Sasson A (2010) Anxiety disorders and sensory over-responsivity in children with autism spectrum disorders: is there a causal relationship? J Autism Dev Disord 40(12):1495–1504

    PubMed  PubMed Central  Google Scholar 

  22. Duvekot J, Ende J, Verhulst FC, Greaves-Lord K (2018) Examining bidirectional effects between the autism spectrum disorder (ASD) core symptom domains and anxiety in children with ASD. J Child Psychol Psychiatr 59(3):277–284

    Google Scholar 

  23. Chang Y-C, Quan J, Wood JJ (2012) Effects of anxiety disorder severity on social functioning in children with autism spectrum disorders. J Dev Phys Disabil 24(3):235–245

    Google Scholar 

  24. Kerns CM, Kendall PC, Zickgraf H, Franklin ME, Miller J, Herrington J (2015) Not to be overshadowed or overlooked: functional impairments associated with comorbid anxiety disorders in youth with ASD. Behav Ther 46(1):29–39

    PubMed  Google Scholar 

  25. Kelly AB, Garnett MS, Attwood T, Peterson C (2008) Autism spectrum symptomatology in children: the impact of family and peer relationships. J Abnorm Child Psychol 36(7):1069–1081

    PubMed  Google Scholar 

  26. Farrugia S, Hudson J (2006) Anxiety in adolescents with asperger syndrome: negative thoughts, behavioral problems, and life interference. Focus Autism Other Dev Disabil 21(1):25–35

    Google Scholar 

  27. South M, Rodgers J, Van Hecke A (2017) Anxiety and ASD: current progress and ongoing challenges. J Autism Dev Disord 47(12):3679–3681

    PubMed  Google Scholar 

  28. Sukhodolsky DG, Bloch MH, Panza KE, Reichow B (2013) Cognitive-behavioral therapy for anxiety in children with high-functioning autism: a meta-analysis. Pediatrics 132(5):e1341–e1350

    PubMed  PubMed Central  Google Scholar 

  29. Hollocks MJ, Lerh JW, Magiati I, Meiser-Stedman R, Brugha TS (2019) Anxiety and depression in adults with autism spectrum disorder: a systematic review and meta-analysis. Psychol Med 49(4):559–572

    PubMed  Google Scholar 

  30. Teh EJ, Chan DME, Tan GKJ, Magiati I (2017) Continuity and change in, and child predictors of, caregiver reported anxiety symptoms in young people with Autism Spectrum Disorder: a follow-up study. J Autism Dev Disord 47(12):3857–3871

    PubMed  Google Scholar 

  31. Swan AJ, Kendall PC, Olino T, Ginsburg G, Keeton C, Compton S et al (2018) Results from the child/adolescent anxiety multimodal longitudinal study (CAMELS): functional outcomes. J Consult Clin Psychol 86(9):738–750

    PubMed  PubMed Central  Google Scholar 

  32. Walkup JT, Albano AM, Piacentini J, Birmaher B, Compton SN, Sherrill JT et al (2008) Cognitive behavioral therapy, sertraline, or a combination in childhood anxiety. N Engl J Med 359(26):2753–2766

    PubMed  PubMed Central  Google Scholar 

  33. Vasa RA, Carroll LM, Nozzolillo AA, Mahajan R, Mazurek MO, Bennett AE et al (2014) A systematic review of treatments for anxiety in youth with autism spectrum disorders. J Autism Dev Disord 44(12):3215–3229

    PubMed  Google Scholar 

  34. Delli CKS, Polychronopoulou SA, Kolaitis GA, Antoniou ASG (2018) Review of interventions for the management of anxiety symptoms in children with ASD. Neurosci Biobehav Rev 95:449–463

    PubMed  Google Scholar 

  35. Williams K, Brignell A, Randall M, Silove N, Hazell P (2013) Selective serotonin reuptake inhibitors for treating people with autism spectrum disorders. Health. https://doi.org/10.1002/14651858.CD004677.pub3

    Article  PubMed  PubMed Central  Google Scholar 

  36. Lewin AB, McGuire JF, Murphy TK, Storch EA (2014) Editorial perspective: the importance of considering parent’s preferences when planning treatment for their children–the case of childhood obsessive-compulsive disorder. J Child Psychol Psychiatr 55(12):1314–1316

    Google Scholar 

  37. Kester KR, Lucyshyn JM (2018) Cognitive behavior therapy to treat anxiety among children with autism spectrum disorders: a systematic review. Res Autism Spectr Disord 52:37–50

    Google Scholar 

  38. Wood JJ, Drahota A, Sze K, Har K, Chiu A, Langer DA (2009) Cognitive behavioral therapy for anxiety in children with autism spectrum disorders: a randomized, controlled trial. J Child Psychol Psychiatr 50(3):224–234

    Google Scholar 

  39. Storch EA, Arnold EB, Lewin AB, Nadeau JM, Jones AM, De Nadai AS et al (2013) The effect of cognitive-behavioral therapy versus treatment as usual for anxiety in children with autism spectrum disorders: a randomized, controlled trial. J Am Acad Child Adolesc Psychiatr 52(2):132–142

    Google Scholar 

  40. Wood JJ, Ehrenreich-May J, Alessandri M, Fujii C, Renno P, Laugeson E et al (2015) Cognitive behavioral therapy for early adolescents with autism spectrum disorders and clinical anxiety: a randomized, Controlled Trial. Behav Ther 46(1):7–19

    PubMed  Google Scholar 

  41. Storch EA, Lewin AB, Collier AB, Arnold E, De Nadai AS, Dane BF et al (2015) A randomized controlled trial of cognitive-behavioral therapy versus treatment as usual for adolescents with autism spectrum disorders and comorbid anxiety. Depress Anxiety 32(3):174–181

    PubMed  Google Scholar 

  42. Kerns CM, Wood JJ, Kendall PC, Renno P, Crawford EA, Mercado RJ et al (2016) The treatment of anxiety in Autism Spectrum Disorder (TAASD) study: rationale, design and methods. J Child Fam Stud 25(6):1889–1902

    PubMed  PubMed Central  Google Scholar 

  43. American Medical Association (2013) CPT: current procedural terminology standard edition, 4th edn. American Medical Association Press, Chicago

    Google Scholar 

  44. Walsh CE, Moody E, Blakeley-Smith A, Duncan A, Hepburn S, Keefer A et al (2018) The relationship between treatment acceptability and youth outcome in group CBT for youth with ASD and anxiety. J Contemp Psychother 48(3):123–132

    Google Scholar 

  45. Peris TS, Rozenman MS, Sugar CA, McCracken JT, Piacentini J (2017) Targeted family intervention for complex cases of pediatric obsessive-compulsive disorder: a randomized controlled trial. J Am Acad Child Adolesc Psychiatr 56(12):1034–1042

    Google Scholar 

  46. Peris TS, Compton SN, Kendall PC, Birmaher B, Sherrill J, March J et al (2015) Trajectories of change in youth anxiety during cognitive-behavior therapy. J Consult Clin Psychol 83(2):239–252

    PubMed  Google Scholar 

  47. Storch EA, Wilhelm S, Sprich S, Henin A, Micco J, Small BJ et al (2016) Efficacy of augmentation of cognitive behavior therapy with weight-adjusted d-cycloserine versus placebo in pediatric obsessive-compulsive disorder: a randomized clinical trial. JAMA Psychiatr 73(8):779–788

    Google Scholar 

  48. Freeman J, Sapyta J, Garcia A, Compton S, Khanna M, Flessner C et al (2014) Family-based treatment of early childhood obsessive-compulsive disorder: the pediatric obsessive-compulsive disorder treatment study for young children (POTS Jr)—a randomized clinical trial. JAMA Psychiatr 71(6):689–698

    Google Scholar 

  49. Silverman WK, Pina AA, Viswesvaran C (2008) Evidence-based psychosocial treatments for phobic and anxiety disorders in children and adolescents. J Clin Child Adolesc Psychol 37(1):105–130

    PubMed  Google Scholar 

  50. Johnco C, Storch EA (2015) Anxiety in youth with autism spectrum disorders: implications for treatment. Expert Rev Neurother 15(11):1343–1352

    PubMed  PubMed Central  Google Scholar 

  51. Selles RR, Storch EA (2013) Translation of anxiety treatment to youth with autism spectrum disorders. J Child Fam Stud 22(3):405–413

    Google Scholar 

  52. Hagopian L, Jennett H (2014) Behavioral assessment and treatment for anxiety for those with autism spectrum disorder. In: Davis Iii TE, White SW, Ollendick TH (eds) Handbook of autism and anxiety. Springer International Publishing, Cham, pp 155–169

    Google Scholar 

  53. Comer JS, Hong N, Poznanski B, Silva K, Wilson M (2019) Evidence base update on the treatment of early childhood anxiety and related problems. J Clin Child Adolesc Psychol 48(1):1–15

    PubMed  Google Scholar 

  54. Lewin AB, Park JM, Jones AM, Crawford EA, De Nadai AS, Menzel J et al (2014) Family-based exposure and response prevention therapy for preschool-aged children with obsessive-compulsive disorder: a pilot randomized controlled trial. Behav Res Ther 56:30–38

    PubMed  Google Scholar 

  55. Lord C, Risi S, Lambrecht L, Cook EH Jr, Leventhal BL, DiLavore PC et al (2000) The autism diagnostic observation schedule-generic: a standard measure of social and communication deficits associated with the spectrum of autism. J Autism Dev Disord 30(3):205–223

    PubMed  Google Scholar 

  56. Rutter M, Le Couteur A, Lord C (2005) Autism diagnostic interview—revised (ADI-R). Western Psychological Services, Los Angeles

    Google Scholar 

  57. Silverman WK, Albano AM (1996) The anxiety disorders interview schedule for DSM-IV: child and parent versions. Oxford University Press, London

    Google Scholar 

  58. RUPP (2002) The pediatric anxiety rating scale (PARS): Development and psychometric properties. J Am Acad Child Adolesc Psychiatr 41(9):1061–1069

    Google Scholar 

  59. Wechsler D (1999) Wechsler abbreviated scale of intelligence. Psychological Corporation, London

    Google Scholar 

  60. Horwitz S, Hoagwood K, Stiffman AR, Summerfield T, Weisz JR, Costello J et al (2001) Measuring youth’s use of mental health services: reliability of the SACA-services assessment for children and adolescents. Psychiatr Serv 52:1088–1094

    PubMed  Google Scholar 

  61. Guy W (1976) Clinical global impressions. National Institute of Mental Health, Rockville

    Google Scholar 

  62. Storch EA, Salloum A, King MA, Crawford EA, Andel R, McBride NM et al (2015) A randomized controlled trial in community mental health centers of computer-assisted cognitive behavioral therapy versus treatment as usual for children with anxiety. Depress Anxiety 32(11):843–852

    PubMed  Google Scholar 

  63. Langley AK, Falk A, Peris T, Wiley JF, Kendall PC, Ginsburg G et al (2014) The child anxiety impact scale (CAIS): examining parent- and child-reported impairment in child anxiety disorders. J Clin Child Adolesc Psychol 43(4):579–591

    PubMed  Google Scholar 

  64. March JS, Parker JDA, Sullivan K, Stallings P, Conners CK (1997) The multidimensional anxiety scale for children (MASC): factor structure, reliability, and validity. J Am Acad Child Adolesc Psychiatr 36(4):554–565

    Google Scholar 

  65. Constantino JN, Gruber CP (2007) Social responsiveness scale (SRS). Western Psychological Services, Los Angeles

    Google Scholar 

  66. Bolte S, Poustka F, Constantino JN (2008) Assessing autistic traits: cross-cultural validation of the social responsiveness scale (SRS). Autism Res 1(6):354–363

    PubMed  Google Scholar 

  67. Achenbach T (2001) Manual for the ASEBA school-age forms and profiles. University of Vermont, Burlington

    Google Scholar 

  68. Whiteside SPH (2009) Adapting the sheehan disability scale to assess child and parent impairment related to childhood anxiety disorders. J Clin Child Adolesc Psychol 38(5):721–730

    PubMed  Google Scholar 

  69. Cooper H, Hedges LV, Valentine JC (2009) The handbook of research synthesis and meta-analysis New York. Russell Sage Foundation, NY

    Google Scholar 

  70. Cohen J (1988) Statistical power analysis for the behavioral sciences Hillsdale. Erlbaum, NJ

    Google Scholar 

  71. Graham JW (2009) Missing data analysis: making it work in the real world. Annu Rev Psychol 60:549–576

    PubMed  Google Scholar 

  72. Donaldson GW, Moinpour CM (2005) Learning to live with missing quality-of-life data in advanced-stage disease trials. J Clin Oncol 23(30):7380

    PubMed  Google Scholar 

  73. Barnard J, Rubin DB (1999) Small-sample degrees of freedom with multiple imputation. Biometrika 86(4):948–955

    Google Scholar 

  74. Reaven JA, Blakeley-Smith A, Culhane-Shelburne K, Hepburn S (2012) Group cognitive behavior therapy for children with high-functioning autism spectrum disorders and anxiety: a randomized trial. J Child Psychol Psychiatr 53(4):410–419

    Google Scholar 

  75. Russell AJ, Jassi A, Fullana MA, Mack H, Johnston K, Heyman I et al (2013) Cognitive behavior therapy for comorbid obsessive-compulsive disorder in high-functioning autism spectrum disorders: a randomized controlled trial. Depress Anxiety 30(8):697–708

    PubMed  Google Scholar 

  76. White SW, Ollendick T, Albano AM, Oswald D, Johnson C, Southam-Gerow MA et al (2013) Randomized controlled trial: multimodal anxiety and social skill intervention for adolescents with autism spectrum disorder. J Autism Dev Disord 43(2):382–394

    PubMed  PubMed Central  Google Scholar 

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Authors and Affiliations

  1. Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, One Baylor Plaza MS:350, Houston, TX, 77030, USA

    Eric A. Storch, Sophie C. Schneider, Stacey C. Grebe, Katherine C. Bergez & Ana Ramirez

  2. Psychology Department, Texas State University, San Marcos, TX, USA

    Alessandro S. De Nadai

  3. University of British Columbia and BC Children’s Hospital, Vancouver, BC, Canada

    Robert R. Selles

  4. Department of Family and Preventive Medicine, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA

    Nicole M. McBride

  5. Department of Psychology, University of Houston, Houston, TX, USA

    Andres G. Viana

  6. Texas Institute of Measurement, Evaluation, and Statistics, University of Houston, Houston, TX, USA

    Andres G. Viana

  7. Department of Pediatrics, Rothman Center for Neuropsychiatry, University of South Florida, Saint Petersburg, FL, USA

    Adam B. Lewin

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  1. Eric A. Storch
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  2. Sophie C. Schneider
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  7. Katherine C. Bergez
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  9. Andres G. Viana
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  10. Adam B. Lewin
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Correspondence to Eric A. Storch.

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Conflict of interest

Dr. Storch receives grant funding from NIH, Red Cross, Houston Greater Community Foundation, Rebuild Texas, and Texas Higher Education Coordinating Board. He is a consultant for Levo Pharmaceuticals. He receives book royalties from Elsevier, APA, Lawrence Erlbaum, Springer, Wiley, Jessica Kingsley and Oxford University Press. Sophie Schneider has received funding from the Texas Higher Education Coordinating Board and the American Red Cross. Dr. De Nadai receives funding from the Henderson-Wessendorff Foundation. Dr. Selles has received research support from the BC Children’s Hospital Research Institute, Michael Smith Foundation for Health Research, speaking honoraria from The AnxietyNZ Trust, and is on the Scientific Advisory Committee for AnxietyCanada. Dr. Lewin receives grant funding from CDC and All Children’s Hospital Research Foundation. He receives book royalties from Springer and Jessica Kingsley. Ms. Bergez, Grebe, Ramirez have no conflicts of interest to disclose.

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All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

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Informed consent was obtained from all adult participants included in the study and assent was obtained from all child participants.

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Storch, E.A., Schneider, S.C., De Nadai, A.S. et al. A Pilot Study of Family-Based Exposure-Focused Treatment for Youth with Autism Spectrum Disorder and Anxiety. Child Psychiatry Hum Dev 51, 209–219 (2020). https://doi.org/10.1007/s10578-019-00923-3

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